RESPIRATORY DISTRESS AND OXYGEN

Patients with terminal illnesses may experience respiratory
distress, difficulty breathing comfortably. Shortness of breath
may be mild or extreme. Persons who have diseases affecting the
lungs or heart disease are especially likely to have shortness of
breath. One of the simplest things one can do to help relieve
shortness of breath is to help the patient to sit up. If you have
a hospital bed, the head of the bed is made to raise up. If the
patient has refused a hospital bed, you can still elevate the
head of the bed by placing a large cushion or two (from a couch
or pillows) evenly under one end of the mattress to elevate your
loved one's head, neck and trunk. A 30 or 45 degree angle of
elevation should be sufficient. This is especially important for
any patient with heart or lung disease.

The next basic thing you can do is to give concentrated oxygen
to the patient. The Attending Physician will ordinarily order
oxygen for any patient who has shortness of breath, or the
hospice RN Case Manager may arrange for oxygen based on
physician-approved Standing Orders for Hospice Care.

Fluid Buildup in the Lungs

In certain cases of heart failure and lung disease, there is a
high probability of fluid building up in the lungs. Medical
science has found that the fluids building up in the lungs can be
minimized by aggressively administering certain medications (such
as scopolamine, hyocyamine, atropine, and other medications, and
in some cases, morphine). Morphine in combination with a diuretic
such as furosemide (lasix) may be very effective when pulmonary
edema is present. If there is any fluid accumulating in the
lungs, the physician may order these or other medications to
remove that extra fluid (See the section on - Fluid Management in
Terminal Illnesses, for more information). If the patient's
lungs are quite "wet" and the patient is unable to
swallow, you may wish to inquire about giving the medications
transdermally (by applying medicated patches to the skin) or
subcutaneously (using an injectable form of medication with very
small needles which are not painful to use).

Administration of Oxygen

Oxygen is most commonly given by nasal cannula which is a
plastic tubing that reaches to the nostrils. It is also given by
a mask which covers the mouth and nose. In both cases, the nasal
cannula or mask are attached to plastic tubing which attaches to
a source of oxygen: oxygen tanks of various sorts or oxygen
concentrators.

Oxygen is given at a certain speed or rate which is measured
in liters per minute. A 2 liter per minute rate is quite common
in adults, although when there is severe shortness of breath, the
rate is increased to 3, 4 or 5 liters/minute in some cases. It is
very important to follow the physician's orders about how
much oxygen to given per minute. In the endstage of a disease
such as Chronic Obstructive Pulmonary Disease (COPD) or
emphysema, suddenly increasing the oxygen to a high rate of flow
could cause worsening respiratory distress or even respiratory
failure, hastening death. If the patient is having difficulty,
consult with your hospice RN case manager who can, if necessary,
call the physician for further medical orders regarding the
oxygen or other medications which might be helpful.

Care Needed When Using Pure Oxygen

When oxygen is given, it is extremely important not to smoke
in the same area or building at all. Smoking, besides being
extremely harmful to the patient, can accidentally cause a fire.
It is important not to have any flames or candles in the room.
Oxygen accelerates the combustion rate and a fire could result.
There are some patients who either ignored this caution or were
confused, and accidentally started to smoke when they had oxygen
coming in by nasal cannula; some of these patients were burnt
severely and in some cases a fire was started in the
building!

If you have oxygen tanks in the room, it is important to
prevent them from falling abruptly. The oxygen is under great
pressure within the tank and the tanks can either explode or
shoot across the room, Serious injury could result if the oxygen
tanks are mishandled. The Medical Equipment Supplier who brings
the tanks will teach you how to use the tanks safely.

Oxygen is an Important Comfort Measure for the
Patient

Providing oxygen to your loved one will help keep him or her
comfortable and reduce the shortness of breath. When patients
become short of breath, anxiety can be dramatically increased
which makes the problem even worse. If you notice that your loved
one is short of breath and no oxygen is yet being provided, ask
the RN case manager to obtain oxygen as soon as possible. In many
hospices, the RN case manager can use the Standing Orders already
approved by the Attending Physician to get oxygen into the home
as soon as the Medical Supply company can bring it out.

If you are told that oxygen isn't necessary, even though
the patient is obviously short of breath, determine exactly why
the RN doesn't think your loved one needs oxygen. If you
personally know a nurse in your area, ask her to come over for a
second opinion. If both of you still think the patient needs
oxygen and the RN is balking at ordering oxygen, demand to speak
with the hospice Medical Director or contact your Attending
physician directly. Insist that your loved one gets the services
needed to maintain comfort! If the attending physician himself
also refuses to order oxygen, you may wish to contact another
physician. There have been reports of kickbacks to physicians who
save money on the care provided to patients by not ordering the
needed services (like oxygen) or medications. This is the same
type of "cost-saving" that sometimes occurs in
HMO's or other insurance plans...it benefits the agency but
does nothing but make the patient suffer more.

Altered Patterns of Breathing

It is quite common for the terminally ill to exhibit altered
patterns of breathing. What this means is that the patient may
breathe abnormally slowly, quickly, may pause for short or very
long periods (called apnea), or may breathe in irregular patterns
or rhythms of breathing. Each pattern or rhythm of irregular
breathing has a specific cause, meaning and interpretation which
experienced hospice physicians and nurses will recognize.

Although you may find it difficult to see your loved one
breathing in these ways, it may be a sign that he or she is in
decline and getting closer to death, or that certain organs are
failing. Longer and longer periods of apnea (pausing when
breathing) can occur, lasting from five to ten seconds or even up
to one minute or more. After these periods of apnea, breathing
again resumes and the pattern may repeat itself. These periods
may get longer as your loved one approaches closer to passing
away, but this does not happen in all cases. Some patients may
breathe extremely fast up to thirty or forty breaths per minute
or more. These altered patterns are to be expected and do not
necessarily mean that the patient is suffering due to that
pattern. Sometimes these altered patterns of breathing continue
for weeks or even months. It is important that you report any
changes in breathing pattern to your RN case manager who can
explain their significance to you.